Provider Demographics
NPI:1922208834
Name:JOHNSON, MELANIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HILL RD
Mailing Address - Street 2:SUITE 18
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-4340
Mailing Address - Country:US
Mailing Address - Phone:415-897-2700
Mailing Address - Fax:415-897-6450
Practice Address - Street 1:1615 HILL RD
Practice Address - Street 2:SUITE 18
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-4340
Practice Address - Country:US
Practice Address - Phone:415-897-2700
Practice Address - Fax:415-897-6450
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16704103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent